Provider Demographics
NPI:1689328213
Name:GOLDMAN, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:GOLDMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18459 N STONEGATE RD
Mailing Address - Street 2:
Mailing Address - City:MARICOPA
Mailing Address - State:AZ
Mailing Address - Zip Code:85138-3719
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18459 N STONEGATE RD
Practice Address - Street 2:
Practice Address - City:MARICOPA
Practice Address - State:AZ
Practice Address - Zip Code:85138-3719
Practice Address - Country:US
Practice Address - Phone:203-617-7970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-11
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10239656251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health